Glp-1 receptor agonists in dementia

ABSTRACT

The present invention relates to improved medical therapies for all forms and stages of dementia involving administration of (i) GLP-1 receptor agonists to subjects with metabolic syndrome or (ii) semaglutide.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.17/736,116, filed May 4, 2022, which is a continuation of InternationalApplication PCT/EP2020/081087 (WO 2021/089678), filed Nov. 5, 2020,which claims priority to European Patent Application 19207501.8, filedNov. 6, 2019 and European Patent Application 20186623.3 filed Jul. 20,2020; the contents of which are incorporated herein by reference.

The present invention relates to GLP-1 receptor agonists for use in thetreatment of all forms and stages of dementia.

INCORPORATION-BY-REFERENCE OF THE SEQUENCE LISTING

The instant application contains a Sequence Listing which has beensubmitted in XML format via the USPTO patent electronic filing systemand is hereby incorporated by reference in its entirety. Said XML file,created on Jun. 7, 2023, is named 190095US03.xml and is 2 kilobytes insize.

BACKGROUND

No treatment options are currently available to actively prevent or slowprogression to dementia and no new pharmacological therapies have beenapproved for the treatment of dementia within the last 20 years.According to WHO, approximately 50 million people worldwide havedementia, this number is projected to triple by 2050, and Alzheimer'sdisease is the most common form of dementia and may contribute to 60-70%of cases. Intensive efforts have so far failed to identify any medicaltreatments that prevent, delay, or modify the disease course ofdementia, including recent unsuccessful trials focusing on reducingproduction or enhancing clearance of amyloid-8. Thus, improvedpharmacological therapies for patients with dementia are desired. It isan important unanswered question to determine whether GLP-1 receptoragonists have an effect on dementia in humans.

SUMMARY

The present invention relates to improved medical therapies for dementiainvolving administration of GLP-1 receptor agonists.

In some embodiments the invention relates to methods for the treatmentof dementia, wherein said method comprises administering a GLP-1receptor agonist to a subject in need thereof, said subject hasmetabolic syndrome, and said GLP-1 receptor agonist comprisesGLP-1(7-37) (SEQ ID No: 1) optionally comprising one or moresubstitutions, deletions, additions and/or modifications.

In some embodiments the invention relates to methods for the treatmentof dementia, wherein said method comprises administering semaglutide toa subject in need thereof.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 shows time to dementia with GLP-1 receptor agonists versusplacebo in pooled RCTs; in the pooled RCTs, 15 patients randomized to aGLP-1 receptor agonist (0.66 per 1000 patient-years) and 32 patientsrandomized to placebo (1.41 per 1000 patient-years) developed dementia.GLP-1 RA=GLP-1 receptor agonists.

FIG. 2 shows hazard ratios for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonists and other second-linediabetes treatments in the nationwide cohort. Cox proportional hazardsregression models conducted for exposure to each treatment. Estimatesdenote the hazard ratio for a 1 year increase in duration of exposure.The models were adjusted for history of stroke, myocardial infarction,hypertension, educational attainment, and diabetes duration. Sex, age,and calendar date were included via matching.

FIG. 3 shows hazard ratios for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonists according to subgroup inthe nationwide cohort. Cox proportional hazards regression modelsconducted for exposure to GLP-1 in various subgroups. Estimates denotethe hazard ratio for a 1 year increase in duration of exposure. Themodels were adjusted for history of stroke, myocardial infarction,hypertension, educational attainment, and diabetes duration. Sex, age,and calendar date were included via matching.

FIG. 4 shows study design used in the nationwide cohort. *First eversecond-line diabetes treatment=first treatment with diabetes treatmentnot including metformin, eligible=eligible for cohort of diabetespatients, case date=date of dementia diagnosis with matching of eachcase to ten controls without dementia, exposure window 5-year windowprior to case date, where duration of cumulative diabetes treatment isassessed.

FIG. 5A shows hazard ratios for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonists and other second-linediabetes. Treatments in the Nationwide Cohort Excluding the Last 2 YearsPrior to Case Date. Cox proportional hazards regression models conductedfor exposure to each treatment. Estimates denote the hazard ratio for a1 year increase in duration of exposure. The models were adjusted forhistory of stroke, myocardial infarction, hypertension, educationalattainment, and diabetes duration. Sex, age, and calendar date wereincluded via matching.

FIG. 5B shows hazard ratios for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonists and other second-linediabetes Treatments in the Nationwide Cohort, where Diabetes Durationwas Defined as “Time Since First Treatment with Metformin or Second-lineDiabetes Treatment”. Cox proportional hazards regression modelsconducted for exposure to each treatment. Estimates denote the hazardratio for a 1 year increase in duration of exposure. The models wereadjusted for history of stroke, myocardial infarction, hypertension,educational attainment, and diabetes duration. Sex, age, and calendardate were included via matching.

FIG. 6A shows hazard ratios for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonists assessed 3, 5, and 10 yearsbefore diagnosis of dementia in the nationwide cohort. *Primaryanalysis. Cox proportional hazards regression models conducted for GLP-1receptor agonist exposure and assessed during a 3, 5, and 10-yearexposure window prior to dementia. Estimates denote the hazard ratio fora 1 year increase in duration of exposure. The models were adjusted forhistory of stroke, myocardial infarction, hypertension, educationalattainment, and diabetes duration. Sex, age, and calendar date wereincluded via matching.

FIG. 6B shows hazard ratio for dementia with each 1 year increase inexposure duration to GLP-1 receptor agonist exposure in the nationwidecohort adjusted for age, sex, and calendar date via matching. Coxproportional hazards regression model conducted for exposure to GLP-1receptor agonists. The estimate denotes the hazard ratio for a 1 yearincrease in duration of exposure. The model was adjusted sex, age, andcalendar date via matching.

FIG. 6C shows hazard ratio for competing risk of death with each 1 yearincrease in exposure duration to GLP-1 receptor agonist in thenationwide cohort. Cox proportional hazards regression model conductedfor exposure to GLP-1 receptor agonists. The estimate denotes the hazardratio for a 1 year increase in duration of exposure. The model wasadjusted for history of stroke, myocardial infarction, hypertension,educational attainment, and diabetes duration. Sex, age, and calendardate were included via matching.

FIG. 7 shows effect on Y-maze alternation behaviour in SAMP8 miceadministration of semaglutide compared to vehicle.

FIGS. 8 and 9 show improvement of long-term memory in SAMP8 mice asmeasured in the step-through passive avoidance test followingadministration of semaglutide compared to vehicle and presentingstep-through latency (FIG. 8 ) and escape latency (FIG. 9 ).

FIG. 10 shows effect of semaglutide in a lipopolysaccharide(LPS)-induced neuroinflammation, a non-genetic model of Alzheimer'sdisease in rodents, on the microglial inflammatory marker lba1 in thehippocampus.

DESCRIPTION

The present inventors surprisingly found that administration ofglucagon-like peptide 1 (GLP-1) receptor agonists reduced the risk ofdementia in subjects with metabolic syndrome. Furthermore, the inventorssurprisingly found that semaglutide improved dementia in animal models.

In some embodiments the invention relates to a method for the treatmentof dementia, wherein said method comprises administering a GLP-1receptor agonist to a subject in need thereof and said subject hasmetabolic syndrome. In some embodiments the invention relates to amethod for the treatment of dementia, wherein said method comprisesadministering a GLP-1 receptor agonist to a human subject in needthereof and said subject has one or more indications selected from thegroup consisting of pre-diabetes, diabetes, cardiovascular disease,obesity, and hypertension. In some embodiments the invention relates toa method for the treatment of dementia, wherein said method comprisesadministering semaglutide to a subject in need thereof.

In some embodiments the invention relates to a method for reducing therisk of developing dementia, wherein said method comprises administeringa GLP-1 receptor agonist to a subject in need thereof and said subjecthas metabolic syndrome. In some embodiments the invention relates to amethod for reducing the risk of developing dementia, wherein said methodcomprises administering a GLP-1 receptor agonist to a subject in needthereof and said subject has one or more indications selected from thegroup consisting of pre-diabetes, diabetes, cardiovascular disease,obesity, and hypertension. In some embodiments the invention relates toa method for reducing the risk of developing dementia, wherein saidmethod comprises administering semaglutide to a subject in need thereof.

Dementia exists in different degrees of severity. In some embodiments,the term “dementia” as used herein refers to all forms of and stages ofthe dementia disease continuum. In some embodiments dementia is selectedfrom the group of indications defined in ICD-11: Dementia due toAlzheimer disease; Dementia due to Alzheimer disease with early onset;Autosomal dominant Alzheimer disease dementia, mutation of presenilin 1;Autosomal dominant Alzheimer disease dementia, mutation of presenilin 2;Autosomal dominant Alzheimer disease dementia, mutation of amyloidprecursor protein; Dementia due to Alzheimer disease with late onset;Alzheimer disease dementia, mixed type, with cerebrovascular disease;Alzheimer disease dementia, mixed type, with other nonvascularaetiologies; Non-amnestic Alzheimer disease dementia subtypes;Non-amnestic Alzheimer disease dementia, logopenic variant; Non-amnesticAlzheimer's disease, logopenic variant with primary progressive aphasia;Non-amnestic Alzheimer disease dementia, visuospatial variant;Non-amnestic Alzheimer's disease, visuospatial variant with posteriorcortical atrophy; Non-amnestic Alzheimer disease dementia, frontalvariant; Alzheimer disease dementia with psychosis; Alzheimer diseasedementia with depression; Dementia due to cerebrovascular disease;Vascular dementia haemorrhagic subtype; Vascular dementia ischaemicsubtype; Multi-infarct dementia; Single strategic infarct dementia;Dementia due to subcortical vascular encephalopathy; Dementia due tohypoxic encephalopathy; Dementia due to genetic causes; Dementia due tocentral nervous system vasculitides; Dementia due to hypertensiveencephalopathy; Dementia due to intracerebral hypertensive haemorrhage;Dementia due to cerebral amyloid angiopathy; Dementia due to Lewy bodydisease; Frontotemporal dementia; Frontotemporal dementia, behaviouralvariant; Frontotemporal dementia, language variant; Frontotemporaldementia, non-fluent or agrammatic variant;

Frontotemporal dementia, semantic variant; Frontotemporal dementia,logopenic variant; Frontotemporal dementia with motor neuron disease;Frontotemporal dementia with familial inclusion body myopathy withPaget's disease of bone; Frontotemporal dementia due to geneticmutation; Frontotemporal dementia due to C9orf72 mutation;Frontotemporal dementia due to MAPT mutation; Frontotemporal dementiadue to VCP mutation; Frontotemporal dementia due to GRN mutation;Frontotemporal dementia due to CHMP2B mutation; Frontotemporal dementiadue to FUS mutation; Frontotemporal dementia due to TARDBP mutation;Frontotemporal dementia due to other or new mutations; Dementia due topsychoactive substances including medications; Dementia due to use ofalcohol; Dementia due to use of sedatives, hypnotics or anxiolytics;Posthallucinogen perception disorder; Dementia due to use of volatileinhalants; Post radiation dementia; Dementia due to carbon monoxidepoisoning; Dementia due to drug intoxication; Dementia or parkinsonismdue to manganese toxicity; Dementia due to diseases classifiedelsewhere; Dementia due to certain specified central nervous systemdegenerative diseases; Dementia due to Parkinson disease; Dementia dueto Huntington disease; Dementia due to corticobasal degeneration;Dementia due to progressive supranuclear palsy; Dementia due toneurofilament inclusion body disease; Dementia due to progressivesubcortical gliosis; Dementia due to multiple system atrophy; Dementiadue to spinocerebellar ataxia; Dementia due to neurodegeneration withbrain iron accumulation; Dementia due to leukodystrophy; Dementia due toParkinsonism-dementia complex of Guam; Dementia due to certain specifiedinfectious diseases; Dementia due to human immunodeficiency virus;Dementia due to neurosyphilis; Dementia due to herpes encephalitis;Dementia due to trypanosomiasis; Dementia due to neurocysticercosis;Dementia due to Lyme disease; Dementia due to Whipple disease; Dementiadue to progressive multifocal leukoencephalopathy; Certain specifiedprimary degenerative dementias; Neurofibrillary tangle dementia;Familial multiple system tauopathy; Argyrophilic grain disease; Dementiadue to certain specified disorders of the central nervous system;Dementia due to multiple sclerosis; Dementia due to prion disease;Dementia due to sporadic Creutzfeldt-Jakob disease; Dementia due tovariant Creutzfeldt-Jakob disease; Dementia due to familialCreutzfeldt-Jakob disease; Dementia due to iatrogenic Creutzfeldt-Jakobdisease; Dementia due to sporadic fatal insomnia; Dementia due to fatalfamilial insomnia; Dementia due to Gerstmann-Staussler-Sheinkersyndrome; Dementia due to Kuru; Dementia due to acute demyelinatingencephalomyelitis; Dementia due to subacute sclerosing panencephalitis;Dementia due to Hashimoto's encephalopathy; Dementia due toparaneoplastic encephalitis; Dementia due to autoimmune encephalitis;Dementia due to primary central nervous system neoplasm; Dementia due tometastatic brain tumour; Dementia due to epilepsy; Dementia due tonormal pressure hydrocephalus; Dementia due to metabolic disordersinvolving the brain; Dementia due to injury to the head; Dementia due tochronic subdural haematoma; Dementia due to obstructive hydrocephalus;Dementia due to exposure to heavy metals and other toxins; Dementia dueto nutritional deficiency; Dementia due to thiamine deficiency; Dementiadue to vitamin B12 deficiency; Dementia due to folate deficiency;Dementia due to vitamin E deficiency; Dementia due to iron deficiency;Dementia due to other nutritional deficiency; Dementia due to pellagra;Dementia due to metabolic abnormalities; Dementia due to hypercalcaemia;Dementia due to acquired hypothyroidism; Dementia due to Wilson disease;Dementia due to dialysis; Dementia due to hepatic failure; Dementia dueto renal failure; Dementia due to chromosomal anomalies; Dementia due toDown syndrome; Dementia due to Fragile X Syndrome; Dementia due torheumatological diseases; Dementia due to polyarteritis nodosa; Dementiadue to systemic lupus erythematosus; Dementia due to Behcet disease;Dementia due to certain specified cause; Behavioural or psychologicaldisturbances in dementia; Psychotic symptoms in dementia; Mood symptomsin dementia; Anxiety symptoms in dementia; Apathy in dementia; Agitationor aggression in dementia; Disinhibition in dementia; Wandering indementia; End stage dementia; Degenerative dementia; Presenile psychoticmental disorder; Paranoid dementia; Presenile dementia not otherwisespecified; Senile dementia; and Old age dementia. In some embodimentsdementia is selected from the group consisting of mild cognitiveimpairment, Alzheimer's disease, mixed dementia, vascular dementia,dementia with Lewy bodies, frontotemporal dementia, pre-senile dementia,and senile dementia. In some embodiments dementia is the Alzheimer'scontinuum with mild cognitive impairment or mild dementia. In someembodiments dementia is mild cognitive impairment, such as mildcognitive impairment of the Alzheimer's type. In some embodimentsdementia is Alzheimer's disease, such as preclinical Alzheimer'sdisease, mild cognitive impairment of the Alzheimer's type, early onsetfamilial Alzheimer's disease, or prodromal Alzheimer's disease. In someembodiments dementia is mild cognitive impairment of the Alzheimer'stype. In some embodiments dementia is mixed dementia. In someembodiments dementia is vascular dementia. In some embodiments dementiais dementia with Lewy bodies. In some embodiments dementia isfrontotemporal dementia. In some embodiments dementia is pre-seniledementia. In some embodiments dementia is senile dementia.

In some embodiments, the term “treatment” as used herein encompassespreventing, delaying, reducing the risk of developing, ameliorating, orcuratively treating the medical indication referred to. Treatment may besymptomatic treatment or disease modifying treatment. In someembodiments, the term treatment as used herein refers to preventing themedical indication referred to. In some embodiments, the term treatmentas used herein refers to delaying (e.g. delaying the onset of) themedical indication referred to. In some embodiments, the term treatmentas used herein refers to reducing the risk of developing the medicalindication referred to. In some embodiments, the term treatment as usedherein refers to ameliorating the medical indication referred to. Insome embodiments, the term treatment as used herein refers to curativelytreating the medical indication referred to.

Subpopulation

The subject to be administered GLP-1 receptor agonists according to thepresent invention may be human, such as an adult human (also referred toas adults). In some embodiments the subject has metabolic syndrome. Asused herein, the term “metabolic syndrome” refers to one or moreindications selected from the group consisting of pre-diabetes,diabetes, cardiovascular disease, obesity, and hypertension. In someembodiments “metabolic syndrome” refers to at least two indicationsselected from the group consisting of pre-diabetes, diabetes,cardiovascular disease, obesity, and hypertension. In some embodiments“metabolic syndrome” refers to at least three indications selected fromthe group consisting of pre-diabetes, diabetes, cardiovascular disease,obesity, and hypertension. In some embodiments the subject haspre-diabetes. In some embodiments the subject has diabetes. In someembodiments diabetes is type 2 diabetes. In some embodiments the subjecthas obesity. In some embodiments the subject has cardiovascular disease.In some embodiments the subject has obesity. In some embodiments obesityis a BMI of at least 25 kg/m², such as at least 27 kg/m² or at least 30kg/m². In some embodiments the subject has hypertension. In someembodiments cardiovascular disease includes one or more of coronaryartery disease (such as angina and myocardial infarction), stroke, heartfailure, hypertensive heart disease, rheumatic heart disease,cardiomyopathy, abnormal heart rhythms, congenital heart disease,valvular heart disease, carditis, aortic aneurysms, peripheral arterydisease, thromboembolic disease, and venous thrombosis. In someembodiments the subject has previously been administered insulin.

GLP-1 Receptor Agonists

The term “GLP-1 receptor agonist” as used herein refers to a compound,which fully or partially activates the human GLP-1 receptor. In someembodiments, the GLP-1 receptor agonist for use in the present inventionis an acylated GLP-1 receptor agonist. The term “acylated” as used inrelation to GLP-1 receptor agonists refers to the GLP-1 receptor agonisthaving covalently attached at least one substituent comprising alipophilic moiety, such as a fatty acid or a fatty diacid. In someembodiments the substituent comprises a fatty acid or a fatty diacid. Insome embodiments, the term GLP-1 receptor agonist as well as thespecific GLP-1 receptor agonists described herein also encompass saltforms thereof.

It follows that the GLP-1 receptor agonist should display “GLP-1activity” which refers to the ability of the compound, i.e. GLP-1receptor agonist, to bind to the GLP-1 receptor and initiate a signaltransduction pathway resulting in insulinotropic action or otherphysiological effects as is known in the art. In some embodiments the“GLP-1 receptor agonist” binds to a GLP-1 receptor, e.g., with anaffinity constant (KD) or activate the receptor with a potency (EC₅₀) ofbelow 1 μM, e.g. below 100 nM as measured by methods known in the art(see e.g. WO 98/08871) and exhibits insulinotropic activity, whereinsulinotropic activity may be measured in vivo or in vitro assays knownto those of ordinary skill in the art. For example, the GLP-1 receptoragonist may be administered to an animal with increased blood glucose(e.g. obtained using an Intravenous Glucose Tolerance Test (IVGTT). Aperson skilled in the art will be able to determine a suitable glucosedosage and a suitable blood sampling regime, e.g. depending on thespecies of the animal, for the IVGTT) and measure the plasma insulinconcentration over time. Suitable assays have been described in such asWO2015/155151.

The term half maximal effective concentration (EC₅₀) generally refers tothe concentration which induces a response halfway between the baselineand maximum, by reference to the dose response curve. EC₅₀ is used as ameasure of the potency of a compound and represents the concentrationwhere 50% of its maximal effect is observed. Due to the albumin bindingeffects of GLP-1 receptor agonists comprising a substituent as describedherein, it is important to pay attention to if the assay includes humanserum albumin or not.

The in vitro potency of the GLP-1 receptor agonist may be determined asdescribed in WO2015/155151, Example 29 without Human Serum Albumin(HSA), and the EC₅₀ determined. The lower the EC₅₀ value, the better thepotency. In some embodiments the potency (EC₅₀) as determined (withoutHSA) is 5-1000 μM, such as 10-750 μM, 10-500 μM or 10-200 μM. In someembodiments the EC₅₀ (without HSA) is at most 500 μM, such as at most300 μM, such as at most 200 μM. In some embodiments the EC₅₀ (withoutHSA) is comparable to human GLP-1(7-37). In some embodiments the EC₅₀(without HSA) is at most 50 μM. In a further such embodiment the EC₅₀ isat most 40 μM, such as at most 30 μM such as at most 20 μM, such as atmost 10 μM. In some embodiments the EC₅₀ is about 10 μM.

Also, or alternatively, the binding of the GLP-1 receptor agonist toalbumin may be measured using the in vitro potency assay of Example 29in WO2015/155151 including HSA. An increase of the in vitro potency,EC₅₀ value, in the presence of serum albumin reflects the affinity toserum albumin. In some embodiments the potency (EC₅₀) as determined(with 1% HSA) is 5-1000 μM, such as 100-750 μM, 200-500 μM or 100-400μM. In some embodiments the EC₅₀ (with 1% HSA) is at most 750 μM, suchas at most 500 μM, such as at most 400 μM, such as at most 300 or suchas at most 250 μM.

If desired, the fold variation in relation to a known GLP-1 receptoragonist may be calculated as EC₅₀(test compound)/EC₅₀(known compound),and if this ration is such as 0.5-1.5, or 0.8-1.2 the potencies areconsidered to be equivalent. In some embodiments the potency, EC₅₀(without HSA), is equivalent to the potency of liraglutide. In someembodiments the potency, EC₅₀ (without HSA), is equivalent to thepotency of semaglutide. In some embodiments the potency, EC₅₀ (with 1%HSA), is equivalent to the potency of liraglutide. In some embodimentsthe potency, EC₅₀ (with 1% HSA), is equivalent to the potency ofsemaglutide.

In some embodiments the GLP-1 receptor agonist comprises one or moresubstitutions, deletions, additions and/or modifications. In someembodiments a modification is a covalently attached substituent. In someembodiments the GLP-1 receptor agonist comprises a peptide which is thehuman GLP-1 (GLP-1(7-37)) or a variant thereof. Human GLP-1, alsoreferred to herein as “GLP-1(7-37)”, has the sequence HAEGTFTSDVSSYLEGQAAKEFIAWLVKGRG (SEQ ID No: 1). In some embodiments the term“variant” refers to a compound which comprises one or more amino acidsubstitutions, deletions, additions and/or modifications. Such additionor deletion of amino acid residues may take place at the N-terminal ofthe peptide and/or at the C-terminal of the peptide. In some embodimentsa simple nomenclature is used to describe the GLP-1 receptor agonist,e.g., [Aib8] GLP-1(7-37) designates a GLP-1(7-37) receptor agonistwherein the naturally occurring Ala in position 8 has been substitutedwith Aib. In some embodiments the GLP-1 receptor agonist comprises amaximum of 12 amino acids which have been altered, e.g., bysubstitution, deletion, insertion and/or modification, compared toGLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 10 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 9 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 8 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 7 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 6 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 5 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 4 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 3 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). In some embodiments the GLP-1 receptoragonist comprises a maximum of 2 amino acids which have been altered,e.g., by substitution, deletion, insertion and/or modification, comparedto GLP-1(7-37) (SEQ ID No: 1). Unless otherwise stated the GLP-1comprises only L-amino acids.

In some embodiments the GLP-1 receptor agonist exhibits at least 60%,65%, 70%, 80% or 90% sequence identity to GLP-1(7-37) over the entirelength of GLP-1(7-37). As an example of a method for determination ofsequence identity between two compounds, the two peptides[Aib8]GLP-1(7-37) and GLP-1(7-37) are aligned. The sequence identity of[Aib8]GLP-1(7-37) relative to GLP-1(7-37) is given by the number ofaligned identical residues minus the number of different residuesdivided by the total number of residues in GLP-1(7-37). Accordingly, insaid example the sequence identity is (31-1)/31.

In some embodiments the C-terminal of the GLP-1 receptor agonist is anamide. In some embodiments the GLP-1 receptor agonist is GLP-1(7-37) orGLP-1(7-36)amide.

In order to prolong the effect of the GLP-1 receptor agonist it ispreferred that the GLP-1 receptor agonist have an extended half-life.The half-life can be determined by method known in the art an in anappropriate model, such as in Male Sprague Dawley rats or minipigs asdescribed in WO2012/140117. Half-life in rats may be determined as inExample 39 and the half-life in minipigs may be determined as in Example37 therein.

In some embodiments the GLP-1 receptor agonist according to theinvention has a half-life above 2 hours in rat. In some embodiments theGLP-1 receptor agonist according to the invention has a half-life above4 hours, such as above 6 hours, such as above 8 hours, such as above 10hours, such as above 12 hours or such as above 15 hours in rat.

In some embodiments the GLP-1 receptor agonist according to theinvention has a half-life above 24 hours in minipig. In some embodimentsthe GLP-1 receptor agonist according to the invention has a half-lifeabove 30 hours, such as above 36 hours, such as above 42 hours, such asabove 48 hours, such as above 54 hours or such as above 60 hours inminipig.

In some embodiments the GLP-1 receptor agonist has a molecular weight ofat most 12 000, such as at most 7 500 Da, such as at most 5 000 Da. Insome embodiments the GLP-1 receptor agonist has a molar mass of at most10 000 g/mol, such as at most 8 000 g/mol, such as at most 6 000 g/mol.

In some embodiments the GLP-1 receptor agonist comprises one or twosubstituents which are covalently attached to the peptide and whereinsaid substituent comprises a lipophilic moiety. In some embodiments thesubstituent comprises a fatty acid or a fatty diacid. In someembodiments the substituent comprises a C16, C18 or C20 fatty acid. Insome embodiments the substituent comprises a C16, C18 or C20 fattydiacid.

In some embodiments the substituent comprises formula (X)

wherein n is at least 13, such as n is 13, 14, 15, 16, 17, 18 or 19. Insome embodiments the substituent comprises formula (X), wherein n is inthe range of 13 to 19, such as in the range of 13 to 17. In someembodiments the substituent comprises formula (X), wherein n is 13, 15or 17. In some embodiments the substituent comprises formula (X),wherein n is 13. In some embodiments the substituent comprises formula(X), wherein n is 15. In some embodiments the substituent comprisesformula (X), wherein n is 17. In some embodiments the substituentcomprises formula (X1a)

HOOC—(C₆H₄)—O—(CH₂)_(m)—CO—*(X1a), wherein m is an integer in the rangeof 6-14. In some embodiments the substituent comprises formula (X1b)

wherein the carboxy group is in position 2, 3 or 4 of the (C₆H₄) groupand wherein m is an integer in the range of 8-11. In some embodimentsthe substituent comprises formula (X1a) or formula (X1b), wherein m isin the range of 6 to 14, such as in the range of 8 to 11. In someembodiments the substituent comprises formula (X1a) or formula (X1b),wherein m is 8, 10 or 12. In some embodiments the substituent comprisesformula (X1a) or formula (X1b), wherein m is 9. In some embodiments thesubstituent comprises formula (X1a) or formula (X1b), wherein m is 11.

In some embodiments the substituent comprises a linker (also referred toas a spacer) located proximally in said substituent to the point ofattachment between said substituent and the peptide in the GLP-1receptor agonist. In some embodiments the substituent comprises a linkerlocated proximally in said substituent to the point of attachmentbetween said substituent and the peptide in said GLP-1 receptor agonist.In some embodiments the substituent comprises one or more8-amino-3,6-dioxaoctanoic acid (OEG), such as two OEG. The one or moreOEG may be a linker.

In some embodiments the substituent is[2-(2-{2-[2-(2-{2-[(S)-4-Carboxy-4-(17-carboxyheptadecanoylamino)butyrylamino]ethoxy}ethoxy)acetylamino]ethoxy}ethoxy)acetyl].

In some embodiments the substituent is[2-(2-{2-[2-(2-{2-[(S)-4-carboxy-4-(17-carboxyheptadecanoylamino)butyrylamino]ethoxy}ethoxy)acetylamino] ethoxy}ethoxy)acetyl]. In someembodiments the substituent is[2-(2-{2-[2-(2-{2-[(S)-4-carboxy-4-({trans-4-[(19-carboxynonadecanoylamino)methyl]cyclohexanecarbonyl}amino)butyrylamino]ethoxy}ethoxy)acetylamino]ethoxy}ethoxy)acetyl].In some embodiments the substituent is{2-[2-(2-{2-[2-(2-{(S)-4-Carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]butyrylamino}-ethoxy)ethoxy]acetylamino}ethoxy)ethoxy]acetyl}.In some embodiments the substituent is{2-[2-(2-{2-[2-(2-{(S)-4-carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]butyrylamino}ethoxy)ethoxy]acetylamino}ethoxy)ethoxy]-acetyl}.In some embodiments the substituent is[2-[2-[2-[[2-[2-[2-[[(4S)-4-carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]-butanoyl]amino]ethoxy]ethoxy]acetyl]amino]ethoxy]ethoxy]acetyl].

In some embodiments the substituent comprises serum albumin, such ashuman serum albumin. In some embodiments the substituent comprises animmunoglobulin domain or fragment, such as a Fc domain or a modifiedIgG4 Fc domain.

In some embodiments the GLP-1 receptor agonist is selected from thegorup consisting of liraglutide, semaglutide, Compound A, and CompoundB. In some embodiments the GLP-1 receptor agonist is liraglutide.Liraglutide is the GLP-1 receptor agonistArg34,Lys26-(N-epsilon-(gamma-L-glutamyl(N-alfa-hexadecanoyl)))-GLP-1(7-37).Liraglutide may be prepared as described in Example 37 of WO98/08871. Insome embodiments the GLP-1 receptor agonist is semaglutide. Semaglutideis the GLP-1 receptor agonistN-epsilon26-[2-(2-{2-[2-(2-{2-[(S)-4-Carboxy-4-(17-carboxyheptadecanoylamino)butyrylamino]ethoxy}ethoxy)acetylamino]ethoxy}ethoxy)acetyl][Aib8,Arg34]GLP-1-(7-37).Semaglutide may be prepared as described in Example 4 of WO2006/097537.In some embodiments the GLP-1 receptor agonist is Compound A, which isdiacylated [Aib8,Arg34,Lys37]GLP-1(7-37) as shown in Example 2 ofWO2011/080103 and namedN^(ε26){2-[2-(2-{2-[2-(2-{(S)-4-Carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]butyrylamino}-ethoxy)ethoxy]acetylamino}ethoxy)ethoxy]acetyl},N^(ε37)-{2-[2-(2-{2-[2-(2-{(S)-4-carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]butyrylamino}ethoxy)ethoxy]acetylamino}ethoxy)ethoxy]-acetyl}-[Aib8,Arg34,Lys37]GLP-1(7-37)—peptide.In some embodiments the GLP-1 receptor agonist is Compound B which isDiacylated[Aib8,Glu22,Arg26,Lys27,Glu30,Arg34,Lys36]-GLP-1-(7-37)-peptidyl-Glu-Glyas shown in Example 31 of WO2012/140117 and namedN^(ε27)-[2-[2-[2-[[2-[2-[2-[[(4S)-4-carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]butanoyl]amino]ethoxy]ethoxy]acetyl]amino]ethoxy]ethoxy]-acetyl],N^(ε36)-[2-[2-[2-[[2-[2-[2-[[(4S)-4-carboxy-4-[10-(4-carboxyphenoxy)decanoylamino]-butanoyl]amino]ethoxy]ethoxy]acetyl]amino]ethoxy]ethoxy]acetyl]-[Aib8,Glu22,Arg26,Lys27,Glu30,Arg34,Lys36]-GLP-1-(7-37)-peptidyl-Glu-Gly. In some embodimentsthe GLP-1 receptor agonist is dulaglutide or albiglutide.

In some embodiments, the GLP-1 receptor agonist is in the form of apharmaceutically acceptable salt, amide, or ester thereof. In someembodiments the GLP-1 receptor agonist comprises one or morepharmaceutically acceptable counter ions.

Pharmaceutical Composition

The GLP-1 receptor agonist may be administered in the form of apharmaceutical composition. The pharmaceutical composition may be in aliquid or solid form.

Parenteral Administration

The pharmaceutical composition may comprise the GLP-1 receptor agonistin a concentration from 0.1 mg/ml to 100 mg/ml. In some embodiments thepharmaceutical composition comprises 0.01-50 mg/ml, or 0.01-20 mg/ml, or0.01-10 mg/ml GLP-1 receptor agonist. In some embodiments thepharmaceutical composition comprises 0.1-20 mg/ml GLP-1 receptoragonist.

The pharmaceutical compositions described herein may further compriseone or more pharmaceutically acceptable excipients, for example selectedfrom the group consisting of buffer system, preservative, tonicityagent, chelating agent, stabilizer and surfactant. In some embodimentsthe pharmaceutical composition comprises one or more pharmaceuticallyacceptable excipients, such as one or more selected from the groupconsisting of a buffer, an isotonic agent, and a preservative. Theformulation of pharmaceutically active ingredients with variousexcipients is known in the art, see e.g. Remington: The Science andPractice of Pharmacy (e.g. 19th edition (1995), and any later editions).The term “excipient” broadly refers to any component other than theactive therapeutic ingredient(s), e.g. the GLP-1 receptor agonist. Theexcipient may be an inert substance, an inactive substance, and/or a notmedicinally active substance.

In some embodiments the pharmaceutical composition has a pH in the rangeof 7.0-10.0, such as 7.0 to 9.5 or 7.2 to 9.5. In some embodiments thepharmaceutical composition has a pH in the range of 7.0-8.5, such as 7.0to 7.8 or 7.8 to 8.2. In some embodiments the pharmaceutical compositionhas a pH of 7.4. In some embodiments the pharmaceutical composition hasa pH of 8.15. In some embodiments the pharmaceutical compositioncomprises a phosphate buffer, such as a sodium phosphate buffer, e.g.disodium phosphate. In some embodiments the pharmaceutical compositioncomprises an isotonic agent, such as propylene glycol. In someembodiments the pharmaceutical composition comprises a preservative,such as phenol.

The pharmaceutical composition may be in the form of a solution or asuspension. In some embodiments the pharmaceutical composition isaqueous composition, such as an aqueous solution or an aqueoussuspension. The term “aqueous composition” is defined as a compositioncomprising at least 50% w/w water. Likewise, the term “aqueous solution”is defined as a solution comprising at least 50% w/w water, and the term“aqueous suspension” is defined as a suspension comprising at least 50%w/w water. An aqueous composition may comprise at least 50% w/w water,or at least 60%, 70%, 80%, or even at least 90% w/w of water.

In some embodiments the GLP-1 receptor agonist is administered in theform of a pharmaceutical composition comprising about 0.1-20 mg/ml GLP-1receptor agonist, about 2-15 mM phosphate buffer, about 2-25 mg/mlpropylene glycol, and has a pH in the range of 7.0-9.0. In someembodiments the GLP-1 receptor agonist is administered in the form of apharmaceutical composition comprising about 0.1-20 mg/ml GLP-1 receptoragonist, about 2-15 mM phosphate buffer, about 2-25 mg/ml propyleneglycol, about 1-18 mg/ml phenol, and has a pH in the range of 7.0-9.0.In some embodiments the GLP-1 receptor agonist (e.g. semaglutide) isadministered in the form of a pharmaceutical composition comprisingabout 1.34 mg/ml GLP-1 receptor agonist (e.g. semaglutide), about 1.42mg/ml disodium phosphate dihydrate, about 14.0 mg/ml propylene glycol,about 5.5 mg/ml phenol, and has pH of about 7.4. In some embodiments theGLP-1 receptor agonist (e.g. semaglutide) is administered in the form ofa pharmaceutical composition comprising 1.34 mg/ml GLP-1 receptoragonist, 1.42 mg/ml disodium phosphate dihydrate, 14.0 mg/ml propyleneglycol, 5.5 mg/ml phenol, and has pH of 7.4. In some embodiments theGLP-1 receptor agonist (e.g. liraglutide) is administered in the form ofa pharmaceutical composition comprising GLP-1 receptor agonist (e.g. 3-8mg/ml), disodium phosphate dihydrate, propylene glycol, phenol, and haspH of about 8.0-8.3. In some embodiments the GLP-1 receptor agonist(e.g. liraglutide) is administered in the form of a pharmaceuticalcomposition comprising GLP-1 receptor agonist (e.g. about 6.0 mg/ml),disodium phosphate dihydrate, propylene glycol, phenol, and has pH ofabout 8.15.

Oral Administration

The solid composition may be a solid composition suited foradministration by the oral route as described further herein. In someembodiments the solid composition comprises at least onepharmaceutically acceptable excipient. The term “excipient” as usedherein broadly refers to any component other than the active therapeuticingredient(s) or active pharmaceutical ingredient(s) (API(s)). Theexcipient may be a pharmaceutically inert substance, an inactivesubstance, and/or a therapeutically or medicinally none activesubstance. The excipient may serve various purposes, e.g. as a carrier,vehicle, filler, binder, lubricant, glidant, disintegrant, flow controlagent, crystallization inhibitors solubilizer, stabilizer, colouringagent, flavouring agent, surfactant, emulsifier or combinations ofthereof and/or to improve administration, and/or absorption of thetherapeutically active substance(s) or active pharmaceuticalingredient(s). The amount of each excipient used may vary within rangesconventional in the art. Techniques and excipients which may be used toformulate oral dosage forms are described in Handbook of PharmaceuticalExcipients, 8th edition, Sheskey et al., Eds., American PharmaceuticalsAssociation and the Pharmaceutical Press, publications department of theRoyal Pharmaceutical Society of Great Britain (2017); and Remington: theScience and Practice of Pharmacy, 22nd edition, Remington and Allen,Eds., Pharmaceutical Press (2013). In some embodiments the excipientsmay be selected from binders, such as polyvinyl pyrrolidone (povidone),etc.; fillers such as cellulose powder, microcrystalline cellulose,cellulose derivatives like hydroxymethylcellulose,hydroxyethylcellulose, hydroxypropylcellulose andhydroxy-propylmethylcellulose, dibasic calcium phosphate, corn starch,pregelatinized starch, etc.; lubricants and/or glidants such as stearicacid, magnesium stearate, sodium stearylfumarate, glycerol tribehenate,etc.; flow control agents such as colloidal silica, talc, etc.;crystallization inhibitors such as Povidone, etc.; solubilizers such asPluronic, Povidone, etc.; colouring agents, including dyes and pigmentssuch as iron oxide red or yellow, titanium dioxide, talc, etc.; pHcontrol agents such as citric acid, tartaric acid, fumaric acid, sodiumcitrate, dibasic calcium phosphate, dibasic sodium phosphate, etc.;surfactants and emulsifiers such as Pluronic, polyethylene glycols,sodium carboxymethyl cellulose, polyethoxylated and hydrogenated castoroil, etc.; and mixtures of two or more of these excipients and/oradjuvants.

The solid composition may comprise a binder, such as povidone; starches;celluloses and derivatives thereof, such as microcrystalline cellulose,e.g., Avicel PH from FMC (Philadelphia, PA), hydroxypropyl cellulosehydroxylethyl cellulose and hydroxylpropylmethyl cellulose METHOCEL fromDow Chemical Corp. (Midland, MI); sucrose; dextrose; corn syrup;polysaccharides; and gelatin. The binder may be selected from the groupconsisting of dry binders and/or wet granulation binders. Suitable drybinders are, e.g., cellulose powder and microcrystalline cellulose, suchas Avicel PH 102 and Avicel PH 200. In some embodiments the solidcomposition comprises Avicel, such as Aavicel PH 102. Suitable bindersfor wet granulation or dry granulation are corn starch, polyvinylpyrrolidone (povidon), vinylpyrrolidone-vinylacetate copolymer(copovidone) and cellulose derivatives like hydroxymethylcellulose,hydroxyethylcellulose, hydroxypropylcellulose andhydroxyl-propylmethylcellulose. In some embodiments the solidcomposition comprises povidone.

In some embodiments the solid composition comprises a filler which maybe selected from lactose, mannitol, erythritol, sucrose, sorbitol,calcium phosphate, such as calciumhydrogen phosphate, microcrystallinecellulose, powdered cellulose, confectioner's sugar, compressible sugar,dextrates, dextrin and dextrose. In some embodiments the solidcomposition comprises microcrystalline cellulose, such as Avicel PH 102or Avicel PH 200.

In some embodiments the solid composition comprises a lubricant and/or aglidant. In some embodiments the composition comprises a lubricantand/or a glidant, such as talc, magnesium stearate, calcium stearate,zinc stearate, glyceryl behenate, glyceryl debehenate, behenoylpolyoxyl-8 glycerides, polyethylene oxide polymers, sodium laurylsulfate, magnesium lauryl sulfate, sodium oleate, sodium stearylfumarate, stearic acid, hydrogenated vegetable oils, silicon dioxideand/or polyethylene glycol etc. In some embodiments the solidcomposition comprises magnesium stearate or glyceryl debehenate (such asthe product Compritol® 888 ATO).

In some embodiments the solid composition comprises a disintegrant, suchas sodium starch glycolate, polacrilin potassium, sodium starchglycolate, crospovidon, croscarmellose, sodium carboxymethylcellulose ordried corn starch. The solid composition may comprise one or moresurfactants, for example a surfactant, at least one surfactant, or twodifferent surfactants. The term “surfactant” refers to any molecules orions that are comprised of a water-soluble (hydrophilic) part, and afat-soluble (lipophilic) part. The surfactant may e.g. be selected fromthe group consisting of anionic surfactants, cationic surfactants,nonionic surfactants, and/or zwitterionic surfactants.

The solid composition may further comprise a delivery agent orabsorption enhancer is for the present invention an excipient capable ofincreasing the oral exposure of the GLP-1 receptor agonist. The deliveryagent may be a salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid (alsoreferred to herein as a salt of NAC), which contains the anionN-(8-(2-hydroxybenzoyl)amino)caprylate. The structural formula ofN-(8-(2-hydroxybenzoyl)amino)caprylate is shown in formula (I).

In some embodiments the salt of N-(8-(2-hydroxybenzoyl)amino)caprylicacid comprises one monovalent cation, two monovalent cations or onedivalent cation. In some embodiments the salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid is selected from the groupconsisting of the sodium salt, potassium salt and/or calcium salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid. In some embodiments the saltof N-(8-(2-hydroxybenzoyl)amino)caprylic acid is selected from the groupconsisting of the sodium salt, potassium salt and/or the ammonium salt.In some embodiments the salt of N-(8-(2-hydroxybenzoyl)amino)caprylicacid is the sodium salt or the potassium salt. Salts ofN-(8-(2-hydroxybenzoyl)amino)caprylate may be prepared using the methoddescribed in e.g. WO96/030036, WO00/046182, WO01/092206 orWO2008/028859. The salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acidmay be crystalline and/or amorphous. In some embodiments the deliveryagent comprises the anhydrate, monohydrate, dihydrate, trihydrate, asolvate or one third of a hydrate of the salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid as well as combinationsthereof. In some embodiments the delivery agent is a salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid as described inWO2007/121318. In some embodiments the delivery agent is sodiumN-(8-(2-hydroxybenzoyl)amino)caprylate (referred to as “SNAC” herein),also known as sodium 8-(salicyloylamino)octanoate.

In some embodiments the composition for use in the invention is in theform of a solid composition, such as a tablet, for oral administration.

In some embodiments the solid composition comprises the GLP-1 receptoragonist in an amount in the range of 0.1-50 mg, such as 0.5 to 40 mg or1-30 mg. In some embodiments the solid composition comprises the GLP-1receptor agonist in an amount in the range of 2-20 mg, such as 3-18 mgor 5-15 mg. In some embodiments the solid composition comprises theGLP-1 receptor agonist in an amount of about 3 mg, such as about 7 mg orabout 14 mg.

In some embodiments least 30% (w/w) of the solid composition (e.g.tablet) is a salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid. In someembodiments least 50% (w/w) of the solid composition (e.g. tablet) is asalt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid. In some embodimentsthe amount of the salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid perdose unit of the composition is in the range of 0.20-.5 mmol, 0.25-1.0mmol, 0.30-0.75 mmol, or such as 0.45-0.65 mmol. In some embodiments theamount of SNAC in the composition is in the range of 75-600 mg. In someembodiments the amount of SNAC in the composition is in the range of75-400 mg, such as from 80-350 mg, such as from about 100 to about 300mg per dose unit.

In some embodiments the solid composition comprises a lubricant, such asmagnesium stearate. In some embodiments a unit dose of the solidcomposition comprises: 0.1-50 mg GLP-1 receptor agonist, 25-600 mg saltof N-(8-(2-hydroxybenzoyl)amino)caprylic acid (NAC) (such as the sodiumsalt of NAC (SNAC)), and 0-25 mg lubricant.

Administration Regimen

GLP-1 receptor agonist may be administered in a therapeuticallyeffective amount, such as an amount therapeutically effective to treattype 2 diabetes. The therapeutically effective amount of GLP-1 receptoragonist can be assessed by a medical doctor. The dosage of GLP-1receptor agonist may be in the range from 0.01 to 50 mg, such as 1-30 mgor 3-20 mg. In some embodiments the GLP-1 receptor agonist isadministered at any time in the day.

The GLP-1 receptor agonist, such as semaglutide, may be administeredonce weekly or more frequent, such as once daily.

In some embodiments the GLP-1 receptor agonist is administered in anamount in the range of 0.05-30 mg per week, such as 0.5 or 1.0 mg perweek, optionally by once weekly administration. In some embodiments theGLP-1 receptor agonist is administered in an amount of at least 0.1 mgper week, such as at least 0.5 mg per week or at least 1 mg per week,optionally by once weekly administration. In some embodiments the GLP-1receptor agonist is administered in an amount of no more than 25 mg perweek, such as no more than 20 mg per week or no more than 15 mg perweek, optionally by once weekly administration. In some embodiments theGLP-1 receptor agonist is administered in an amount of no more than 10mg per week, such as no more than 6 mg per week or no more than 3 mg perweek, optionally by once weekly administration. In some embodiments theGLP-1 receptor agonist is administered once weekly in an amount of 0.5or 1.0 mg.

In some embodiments the method of the invention reduces the risk ofmortality.

In some embodiments the administration of a GLP-1 receptor agonist is achronic treatment in which semaglutide is administered for at least 12months, such as for at least 16 months or at least 18 months.

Parenteral Administration

The GLP-1 receptor agonist may be administered via parenteraladministration, for example subcutaneous injection. GLP-1 receptoragonist may be administered using a pen-injector, such as a 3 mldisposable pen-injector.

In some embodiments the dosage of GLP-1 receptor agonist is in the rangefrom 0.1 to 5.0 mg, such as in the range from 0.1 to 3.0 mg. In someembodiments the daily dosage of GLP-1 receptor agonist is selected fromthe group consisting of 0.5 and 1.0 mg.

Oral Administration

The GLP-1 receptor agonist may be administered orally, for example inthe form of a tablet, a coated tablet, a sachet or a capsule such ashard or soft gelatine capsule and all such compositions are consideredsolid oral dosage forms. Oral administration may be once dailyadministration. In some embodiments the dosage of the GLP-1 receptoragonist is in the range from 1 to 30 mg, such as 2 to 20 mg or 3 to 15mg. In some embodiments the dosage of GLP-1 receptor agonist is 3, 7 or14 mg. The composition may be in the form of a dose unit, such astablet. In some embodiments the weight of the unit dose is in the rangeof 50 mg to 1000 mg, such as in the range of 50-750 mg, or such as about100-500 mg. In some embodiments the weight of the dose unit is in therange of 75 mg to 350 mg, such as in the range of 50-300 mg or 100-400mg. The tablet for oral administration may comprise 30% (w/w) salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid, such as the sodium salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid (SNAC). In some embodimentsthe composition may be granulated prior to being compressed to tablets.The composition may comprise a granular part and/or an extra-granularpart, wherein the granular part has been granulated and theextra-granular part has been added after granulation. The GLP-1 receptoragonist may be included in the granular part or the extra-granular part.In some embodiments the extra-granular part comprises the GLP-1 receptoragonist. In an embodiment the extra-granular part may further comprise alubricant and/or a glidant. In an embodiment the granular part maycomprise a lubricant and/or a glidant. In an embodiment the granularpart and the extra-granular part comprise a lubricant and/or a glidant.

In some embodiments, the GLP-1 receptor agonist is the solepharmaceutically active ingredient administered according to the presentinvention. In some embodiments, the GLP-1 receptor agonist is combinedwith one or more further pharmaceutically active ingredients in thepresent invention. In some embodiments, the GLP-1 receptor agonist iscombined with one or more further pharmaceutically active ingredientsselected from the group consisting of rivastigmin, menantine (such asmenantine hydrochloride), donepezil and galantamine. In someembodiments, the GLP-1 receptor agonist is combined with rivastigmin. Insome embodiments, the GLP-1 receptor agonist is combined with menantine,such as menantine hydrochloride. In some embodiments, the GLP-1 receptoragonist is combined with donepezil. In some embodiments, the GLP-1receptor agonist is combined with galantamine.

In some embodiments the term “chronic treatment” as used herein withreference to the GLP-1 receptor agonist means administration in anamount and frequency to provide a therapeutic effect. In someembodiments the term “chronic treatment” as used herein with referenceto GLP-1 receptor agonist means once weekly administration of 0.1-3.0mg, such as 0.5 or 1.0 mg, GLP-1 receptor agonist (e.g. semaglutide). Insome embodiments the term “chronic treatment” as used herein withreference to a GLP-1 receptor agonist means once daily administration of0.05-0.3 mg, such as 0.05, 0.1, 0.2, or 0.3 mg, GLP-1 receptor agonist(e.g. semaglutide). In some embodiments the term “chronic treatment” asused herein with reference to a GLP-1 receptor agonist means once dailyadministration of 0.1-6 mg, such as 0.5-4 mg, GLP-1 receptor agonist(e.g. liraglutide). The term “chronic treatment” as used herein mayrefer to administration of a drug according to a prescribed dosageregimen (for example once weekly administration) for a long period oftime (for example at least 2 years or at least 5 years) wherein up to10%, such as up to 5%, of dosages may be missed; provided that no morethan 10 consecutive dosages are missed.

Unless otherwise stated, ranges herein include their end points. In someembodiments the term “a” means “one or more”. In some embodiments, andunless otherwise indicated in the specification, terms presented insingular form also include the plural situation. Herein the term “about”means±10% of the value referred to, and includes the value.

Non-Limiting Embodiments of the Invention

Non-limiting embodiments of the invention include:

-   -   1. A method for the treatment of dementia, wherein said method        comprises administering a GLP-1 receptor agonist to a subject in        need thereof and said subject has metabolic syndrome.    -   2. A method for the treatment of dementia, wherein said method        comprises administering semaglutide to a subject in need        thereof.    -   3. A method for reducing the risk of developing dementia,        wherein said method comprises administering a GLP-1 receptor        agonist to a human subject in need thereof and said subject has        one or more indications selected from the group consisting of        pre-diabetes, diabetes, cardiovascular disease, obesity, and        hypertension.    -   4. A method for reducing the risk of developing dementia,        wherein said method comprises administering a GLP-1 receptor        agonist to a subject in need thereof and said subject has        metabolic syndrome.    -   5. A method for reducing the risk of developing dementia,        wherein said method comprises administering a GLP-1 receptor        agonist to a subject in need thereof and said subject has one or        more indications selected from the group consisting of        pre-diabetes, diabetes, cardiovascular disease, obesity, and        hypertension.    -   6. A method for reducing the risk of developing dementia,        wherein said method comprises administering semaglutide to a        subject in need thereof.    -   7. The method according to any one of the preceding embodiments,        wherein treatment is reducing the risk of developing dementia.    -   8. The method according to any one of the preceding embodiments,        wherein said metabolic syndrome is one or more indications        selected from the group consisting of pre-diabetes, diabetes,        cardiovascular disease, obesity, and hypertension.    -   9. The method according to any one of the preceding embodiments,        wherein said subject has pre-diabetes.    -   10. The method according to any one of the preceding        embodiments, wherein said subject has diabetes.    -   11. The method according to any one of the preceding        embodiments, wherein said subject has cardiovascular disease.    -   12. The method according to any one of the preceding        embodiments, wherein said subject has obesity.    -   13. The method according to any one of the preceding        embodiments, wherein said subject has hypertension.    -   14. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises        GLP-1(7-37) (SEQ ID No: 1) optionally comprising one or more        substitutions, deletions, additions and/or modifications.    -   15. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises a        maximum of 12 amino acids which have been altered, e.g., by        substitution, deletion, insertion and/or modification, compared        to GLP-1(7-37) (SEQ ID No: 1).    -   16. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises a        maximum of 10 amino acids which have been altered, e.g., by        substitution, deletion, insertion and/or modification, compared        to GLP-1(7-37) (SEQ ID No: 1).    -   17. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises a        maximum of 8 amino acids which have been altered, e.g., by        substitution, deletion, insertion and/or modification, compared        to GLP-1(7-37) (SEQ ID No: 1).    -   18. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises a        maximum of 6 amino acids which have been altered, e.g., by        substitution, deletion, insertion and/or modification, compared        to GLP-1(7-37) (SEQ ID No: 1).    -   19. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist comprises one        or more substituents.    -   20. The method according to any one of the preceding        embodiments, wherein said substituent comprises a linker, such        as one or more OEG.    -   21. The method according to any one of the preceding        embodiments, wherein said linker is located proximally in said        substituent to the point of attachment between said substituent        and the peptide in said GLP-1 receptor agonist.    -   22. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist has an EC₅₀        (without HSA) of at most 500 μM.    -   23. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is no more than        12 kDa.    -   24. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is selected        from the group consisting of liraglutide, semaglutide, Compound        A and Compound B.    -   25. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is liraglutide.    -   26. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is semaglutide.    -   27. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is Compound A.    -   28. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is Compound B.    -   29. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is dulaglutide.    -   30. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is albiglutide.    -   31. The method according to any one of the preceding        embodiments, wherein said subject is human.    -   32. The method according to any one of the preceding        embodiments, wherein said dementia is all forms and all stages        in the dementia disease continuum.    -   33. The method according to any one of the preceding        embodiments, wherein said dementia is mild cognitive impairment.    -   34. The method according to any one of the preceding        embodiments, wherein said dementia is Alzheimer's disease.    -   35. The method according to any one of the preceding        embodiments, wherein said dementia is selected from the group        consisting of preclinical Alzheimer's disease, mild cognitive        impairment of the Alzheimer's type, early onset familial        Alzheimer's disease, and prodromal Alzheimer's disease.    -   36. The method according to any one of the preceding        embodiments, wherein said dementia is preclinical Alzheimer's        disease.    -   37. The method according to any one of the preceding        embodiments, wherein said dementia is mild cognitive impairment        of the Alzheimer's type.    -   38. The method according to any one of the preceding        embodiments, wherein said dementia is early onset familial        Alzheimer's disease.    -   39. The method according to any one of the preceding        embodiments, wherein said dementia is prodromal Alzheimer's        disease.    -   40. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is the sole        pharmaceutically active ingredient administered to said subject.    -   41. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is administered        subcutaneously.    -   42. The method according to the preceding embodiment, wherein        said GLP-1 receptor agonist is administered in a composition        which is in the form of a solution or suspension.    -   43. The method according to the preceding embodiment, wherein        said composition comprises at least 90% water.    -   44. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is semaglutide,        is administered subcutaneously, and is in the form of a solution        comprising at least 90% water and with pH in the range of        7.0-9.0.    -   45. The method according to any one of the preceding        embodiments, wherein said GLP-1 receptor agonist is administered        orally.    -   46. The method according to the preceding embodiment, wherein        said GLP-1 receptor agonist is administered in the form of a        tablet.    -   47. The method according to the preceding embodiment, wherein at        least 30% (w/w) of said tablet is a salt of        N-(8-(2-hydroxybenzoyl)amino)caprylic acid.    -   48. The method according to the preceding embodiment, wherein at        least 50% (w/w) of said tablet is a salt of        N-(8-(2-hydroxybenzoyl)amino)caprylic acid.    -   49. The method according to the preceding embodiment, wherein        said salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid is SNAC.    -   50. The method according to any one of the preceding        embodiments, wherein said subject has previously been        administered insulin.    -   51. The method according to any one of the preceding        embodiments, wherein said method reduces the risk of mortality        for said subject.    -   52. The method according to any one of the preceding        embodiments, wherein said administration of a GLP-1 receptor        agonist is a chronic treatment in which semaglutide is        administered for at least 12 months, such as for at least 16        months or at least 18 months.

EXAMPLES Example 1—Reduced Risk of Dementia in Subjects with MetabolicSyndrome Methods

Exposure to GLP-1 receptor agonist and subsequent diagnosis of dementiawas assessed in data sources with long term treatment exposure includingthree pooled double-blind randomized controlled trials (RCTs) and anationwide cohort of patients with diabetes. This was done with the aimof investigating whether use of GLP-1 receptor agonists reduces theonset of dementia in patients with diabetes.

Trials and Registries

A triangulation approach integrating study designs and data sources withdifferent key sources of potential bias was employed to obtain a morereliable answer. First, data was pooled from three large RCTs with GLP-1receptor agonists; liraglutide (LEADER; 9,340 patients), subcutaneoussemaglutide (SUSTAIN-6; 3,297 patients), and oral semaglutide (PIONEER6; 3,183 patients). All three trials were multicenter, double-blind,placebo-controlled cardiovascular outcomes trials. Patients with type 2diabetes at high risk for or with established cardiovascular diseasewere randomly assigned in a 1:1 ratio, to receive placebo or liraglutide(LEADER), or semaglutide (SUSTAIN-6; PIONEER 6) in addition to standardof care. In these trials, the treatment for diabetes (excluding GLP-1receptor agonists, dipeptidyl peptidase-4 inhibitors (DPP4 inhibitors),and pramlintide) was adjusted or added in both arms, at theinvestigator's discretion, as previously described. The formulationtested in LEADER was an aqueous composition comprising liraglutide,disodium phosphate dihydrate, propylene glycol, and phenol at pH 8.15.The formulation tested in SUSTAIN-6 was an aqueous compositioncomprising semaglutide, disodium phosphate dihydrate, propylene glycol,and phenol at pH 7.4. The formulation tested in PIONEER was a tabletcomprising semaglutide and SNAC.

Next, we used the Danish National Prescription Register, which holdsinformation on all redeemed prescriptions in Denmark since Jan. 1, 1995(Table S1), to identify a nationwide cohort of patients treated fordiabetes. We identified everyone with a first prescription of a secondline diabetes treatment (Table S2) between Jan. 1, 1995 and Dec. 31,2017.

Follow-up for onset of dementia started on Jan. 1, 2009 (FIG. 4 ), asthis was when GLP-1 receptor agonists could be considered a well-knownand available treatment for diabetes in Denmark. To correctly identifypatients with a first ever prescription for a second line diabetestreatment, we excluded those who had a prescription between Jan. 1, 1995through Jun. 30, 1995. Furthermore, patients with established dementiabefore start of follow-up or who developed dementia before age 50 wereexcluded.

For the main analysis we included everyone with at least 5 years ofexposure to second line diabetes treatment.

Exposure to GLP-1 Receptor Agonists

The predefined treatment durations for the 3 RCTs are listed inSupplementary Table S4. In the nationwide cohort, all dispensedprescriptions for GLP-1 receptor agonists were identified (Table S2),and years of cumulative GLP-1 receptor agonist exposure were updatedthroughout the follow-up period. Patients were considered exposed ifthey had redeemed at least 1 prescription for any GLP-1 receptoragonists. The exposure duration was accumulated according to 6 monthslong intervals, in which at least 1 prescription was redeemed.

Exposure to Other Diabetes Treatments

In the nationwide cohort, “other second line diabetes treatments” wereassessed to test whether or not a potential influence of GLP-1 receptoragonists on dementia prevention was specific for treatment with GLP-1receptor agonists. We identified other second line diabetes treatmentthat were available as alternative treatment options to GLP-1 receptoragonists during the follow-up period, i.e. insulin, sulfonylureas, DPP4inhibitors, acarbose, and meglitinides (Table S2). Exposure time wasaccumulated according to six months long intervals, in which at least 1prescription was redeemed. Monotherapy with metformin was not assessed,since this is considered first-line treatment for diabetes and thus nota comparable treatment option to GLP-1 receptor agonists.

Dementia

In the RCTs, the Standardized Medical Dictionary for RegulatoryActivities (MedDRA, version 21.1) was used to identify dementia-relatedadverse events using the narrow scope search terms for dementia (TableS3). In the nationwide cohort, dementia was defined as a diagnosis ofdementia in the National Patient Register or first ever prescription forapproved dementia specific treatment in the National PrescriptionRegister (cholinesterase inhibitors and memantine) (Table 51 and S2lists the ICD10 and ATC codes).

Statistical Analysis

For the pooled RCTs, an intention-to-treat analysis was performed usingCox regression with treatment assignment as the only explanatoryvariable to determine the hazard ratio for developing dementia withGLP-1 receptor agonists versus placebo. We reported the hazard ratio fordementia for patients randomized to a GLP-1 receptor agonist versusplacebo. The incidence of dementia with death as competing risk wascalculated using the Aalen-Johansen estimator.

In the nationwide cohort we employed a nested case-control study designwhere each patient at case date (date of dementia diagnosis) was matchedon age, sex and calendar date to 10 controls without dementia. Theeffects of differences in cumulative exposure to GLP-1 receptor agonistsfor developing dementia were modelled with Cox regression in a 5 yearexposure window prior to case date (FIG. 4 ) and reported as hazardratios for each 1 year increase in GLP-1 receptor agonist exposure forcases versus controls. Reported were hazard ratios for each 1 yearincrease in duration of. The model was adjusted for age, sex, andcalendar date via matching, and information on diabetes duration (yearssince first ever prescription of any second line diabetes treatment),stroke, myocardial infarction, hypertension, chronic renal disease, andeducational attainment (Table 51 and S2) at the start of the exposurewindow. A similar Cox regression model was employed for each of theother second line diabetes treatments. Furthermore, the hazard ratio fordementia with exposure to GLP-1 receptor agonists was investigatedacross subgroups, including sex, age, insulin exposure, andcardiovascular status, where cardiovascular disease was defined as priorstroke or myocardial infarction. In the nationwide cohort, prespecifiedsensitivity analyses were performed to determine the effect of 1)reverse causation, where exposure two years before the case date wasignored; 2) diabetes duration defined as “time since first treatmentwith metformin or second line diabetes treatment; 3) shortening andlengthening the exposure windows (3- and 10-years, respectively); 4)adjustment only via matching on age, sex, and calendar date and 5)competing risk of death. The level of statistical significance was setat 5%.

Results Study Populations

In total, 15,820 patients at high risk for or with establishedcardiovascular disease were randomized to a GLP-1 receptor agonist orplacebo in the pooled RCTs. Baseline characteristics are presented inTable 1.

In the nationwide cohort of 120,054 patients with at least 5 years sinceinitiation of a second line diabetes treatments, 4,849 patientsdeveloped dementia during the follow-up period from 2009 through 2017.Characteristics of case and control patients are presented in Table 2.Liraglutide comprised 95% of all prescriptions for GLP-1 receptoragonists.

Dementia in Pooled RCTs

In the pooled RCTs, 15 patients randomized to a GLP-1 receptor agonistand 32 patients randomized to placebo developed dementia during a medianfollow-up of 3.61 years (Table S4).

Patients randomized to GLP-1 receptor agonists had a lower risk ofdeveloping dementia compared to those randomized to placebo (hazardratio 0.47; 95% confidence interval (CI), 0.25 to 0.86) (FIG. 1 andTable S5). The beneficial effects of GLP-1 receptor agonists becameapparent after 12 months of treatment (FIG. 1 ).

Dementia in the Nationwide Cohort

The median follow-up time in the nationwide cohort was 7.4 years. Theanalysis nested in the nationwide cohort was specifically designed toexamine long term effects by ensuring at least 5 years of treatment withsecond line diabetes therapy. The result was a reduction of hazard ofdementia with increasing duration of GLP-1 receptor agonist exposure(FIG. 2 ). Exposure to other second line diabetes treatments was notfound to be associated with a decrease in hazard ratio (FIG. 2 ). Thereduction in hazard ratio for dementia with exposure to GLP-1 receptoragonists was similar across subgroups stratified by sex, age,co-exposure to insulin, and cardiovascular status (FIG. 3 ).

The results were not changed by excluding exposure in the two yearsleading up to the diagnosis of dementia (FIG. 5A), and when diabetesduration was assessed as “time since first treatment with metformin orsecond line diabetes treatment”, although an association with DDP4inhibitors was found to be protective against dementia (FIG. 5B).Furthermore, the results for dementia remained unchanged when exposureto GLP-1 receptor agonists was assessed within 3 and 10 years beforediagnosis of dementia (FIG. 6A). Adjusting for only age, sex, andcalendar date via matching also yielded the same results (FIG. 6B).Lastly, the analysis of death as competing risk, which assessed thehazard ratio for death without a previous dementia diagnosis, showed alower hazard ratio for death with exposure to GLP-1 receptor agonists(FIG. 6C).

In conclusion, it was found that treatment with GLP-1 receptor agonistswas associated with a reduced risk of dementia in patients withdiabetes.

TABLE 1 Baseline Characteristics in the Pooled RCTs GLP-1 ReceptorAgonist Placebo Characteristics (N = 7,907) (N = 7,913) Male sex - no.(%) 5108 (64.6) 5073 (64.1) Age - no. (%) 64.6 (7.2) 64.8 (7.3) <70 5942(75.2) 5850 (73.9) 70-80 1764 (22.3) 1864 (23.6) 80-90 198 (2.5) 198(2.5) >90 3 (0.4) 1 (0.01) Diabetes duration - mean (±SD) 13.5 (8.2)13.5 (8.2) Stroke - no. (%) 1229 (15.5) 1299 (16.4) Myocardialinfarction - no. (%) 2554 (32.3) 2531 (32.0) Hypertension - no. (%)*5804 (91.9) 5766 (91.2) Chronic renal disease - no. (%)^(†) 189 (2.4)173 (2.2) *Not including the PIONEER 6 trial. ^(†)Chronic renal diseaseis defined as eGFR < 30.

TABLE 2 Characteristics of the Case and Control Patients in theNationwide Cohort Cases Controls Characteristics (N = 4,849) (N =48,506) Male sex - no. (%) 2299 (47.4) 22998 (47.4) Age - no (%) <701278 (26.4) 12784 (26.4) 70-80 2268 (46.8) 22688 (46.8) 80-90 1260(26.0) 12612 (26.0) >90 43 (0.9) 422 (0.9) Diabetes duration - mean(±SD)*^(†) 6.6 (4.1) 6.4 (4.1) GLP-1 receptor agonists - no. (%)   0years 4575 (94.3) 44594 (91.9) 1-2 years 59 (1.2) 623 (1.3) 2-3 years 35(0.7) 586 (1.2) 3-4 years 35 (0.7) 483 (1.0) 4-5 years 74 (1.5) 1076(2.2) Stroke - no. (%) 760 (15.7) 5628 (11.6) Myocardial infarction -no. (%) 527 (10.9) 5241 (10.8) Hypertension - no. (%)* 3252 (67.1) 31961(65.9) Chronic renal disease - no. (%)^(†) 233 (4.8) 2287 (4.7)Educational attainment - no. (%)^(‡) Basic 2490 (51.4) 23920 (49.3)Medium 1508 (31.1) 14971 (30.9) Advanced 427 (8.8) 4681 (9.7) *Timesince initiation of second-line diabetes treatment. ^(†)At beginning of5-year exposure window, ^(‡)In patients who received GLP-1 receptoragonists. ∫ Educational status unknown in 424 (8.7%) cases and in 4934(10.2%) controls.

TABLE S1 Data Sources. Registers/databases/ Data Source Clinical Trialinformation Variables Pooled RCTs LEADER ClinicalTrials.gov number,Liraglutide versus placebo NCT01179048. Multicenter, double-blind,placebo-controlled trial conducted at 410 sites in 32 countriesSUSTAIN-6 ClinicalTrials.gov number, Subcutaneous semaglutideNCT01720446. versus placebo Multicenter, double-blind,placebo-controlled trial conducted at 230 sites in 20 countries PIONEER6 ClinicalTrials.gov number, Oral semaglutide versus placebo NCT02692716Multicenter, double-blind, placebo-controlled trial conducted at 214sites in 21 countries Nationwide The Danish Diagnosis of: cohortNational Patient Register Dementia, hypertension, myocardial infarction,stroke, and chronic renal disease The Danish register of MedicinalTreatment for: Product Statistics Dementia, diabetes, and hypertensionDanish Register of Causes of Vital status, causes of death DeathPopulation Education Register Educational attainment

TABLE S2 Overview of Definitions of Diabetes Treatments, Dementia, andComorbidities for the Nationwide Cohort. Condition/treatment ATC codesand ICD codes Diabetes treatments (ATC codes) Metformin A10BA02 GLP-1receptor agonists A10BJ Insulin A10A Acarbose A10BF DPP4 inhibitorsA10BH Sulfonylureas A10BB Meglitinides A10BX TZD* A10BG SGLT-2i* A10BKDementia** (ATC codes) Donepezil N06DA02 Rivastigmine N06DA03Galantamine N06DA04 Memantine N06DX01 (ICD codes) DF00, DG30, DF01,DF023, DF028, DF03 Comorbidities (ICD codes) Hypertension ICD-10:DI10-DI13, DI15 ATC: C02-C03, C07, C09 Myocardial infarction ICD-8: 410ICD-10: DI21, DI22 Stroke ICD-8: 433-438 ICD-10: DI63, DI64, DG458,DG459 Chronic renal disease ICD-8: 25002, 40039, 59009, 59320,75310-75311, 75319 ICD-10: DN158-DN159, DQ612-DQ613, DQ615, DG619,DE102, DE112 DE132, DE142, DI120, DN160, DN162- DN164, DN168, DM300,DM313, DM319, DM321B *These products were not available at the samecalendar period as GLP-1 receptor agonists and thus were not consideredalternative treatment options to GLP-1 receptor agonists. *The last 6months of 2017, dementia was only defined by dementia treatments due toregister availability.

TABLE S3 Dementia (Narrow Scope) Standardized MedDRA Queries (SMQs)Search Terms* Applied in the Post Hoc Analysis of the Pooled RCTs. NameScope Clinical dementia rating scale score abnormal Narrow Corticobasaldegeneration Narrow Creutzfeldt-Jakob disease Narrow Dementia NarrowDementia Alzheimer's type Narrow Dementia of the Alzheimer's type,uncomplicated Narrow Dementia of the Alzheimer's type, with deliriumNarrow Dementia of the Alzheimer's type, with delusions Narrow Dementiaof the Alzheimer's type, with depressed mood Narrow Dementia with Lewybodies Narrow Early onset familial Alzheimer's disease NarrowFrontotemporal dementia Narrow Hippocampal sclerosis Narrow Korsakoff'ssyndrome Narrow Mini mental status examination abnormal Narrow Mixeddementia Narrow Presenile dementia Narrow Prion disease NarrowProgressive supranuclear palsy Narrow Scatolia Narrow Senile dementiaNarrow Variant Creutzfeldt-Jakob disease Narrow Vascular dementia Narrow*version 21.1

TABLE S4 Prespecified Sensitivity Analyses in the Nationwide Cohort.Sensitivity Analyses 1) Reverse causation, where exposure two yearsbefore the case date was ignored 2) Diabetes duration defined as “timesince first treatment with metformin or second line diabetes treatment3) Shortening and lengthening the exposure windows (3- and 10-years,respectively) 4) Adjustment only via matching on age, sex, and calendardate 5) Competing risk of death

TABLE S5 Median Follow-up and Rates of Dementia in each of the IncludedRCTs. Dementia SMQ GLP-1 Receptor Dementia SMQ Median Agonists PlaceboTreatment Follow-up no. of no. of RCT Groups Duration events rate eventsrate LEADER* Liraglutide 3.8 years 12 0.69 25 1.45 EX2211-3748 vs.placebo SUSTAIN-6† Semaglutide (s.c) 2.1 years 3 0.88 5 1.47 NN9535-3744vs. placebo PIONEER 6‡ Semaglutide (oral) 1.3 years 0 2 0.96 NN9924-4221vs. placebo *In LEADER, the minimum planned follow-up was 42 months,with a maximum of 60 months of receiving the assigned regimen andsubsequently 30 days of follow-up. †In SUSTAIN-6 the planned observationperiod was 109 weeks, consisting of 104 weeks of the assigned regimenand subsequently 5 weeks of follow-up. ‡In PIONEER 6, no predefinedminimum treatment duration was required, but follow-up was required tocontinue until 122 events of the primary outcome had occurred.

TABLE S6 Hazard Ratio for Dementia in the Pooled RCTs according toDementia Subtypes. GLP-1 Receptor Agonist Placebo Hazard Ratio forDiagnoses no. of patients no. of patients Dementia (95% CI) Dementia 615 Dementia Alzheimer's 5 7 type Dementia with Lewy 0 2 bodies Mixeddementia 2 2 Senile dementia 1 3 Vascular dementia 1 3 Total 15 (0.19%)32 (0.40%) 0.47 (0.25-0.86)

Example 2—Semaglutide Prevents Cognitive Decline in the SenescenceAccelerated Prone 8 (SAMP8) Mouse

The inbred senescence-accelerated mouse-prone 8 (SAMP8) model is anon-transgenic mouse line that displays phenotypes associated withsporadic (not driven by a defined genetic cause) Alzheimer's dementia,including measurable cognitive decline. SAMP8 mice display acceleratedageing and thus also model age-related metabolic complications, showingincreased markers of oxidative stress and inflammation. As cognitivedeficits can be measured in this model prior to the presence of overtneuropathology such as the accumulation of amyloid plaques in the brain,this mouse model allows for the assessment of drug effects on preventingcognitive decline and models early stages of disease in humans.

Here, SAMP8 mice were utilized to characterize the impact of semaglutidetreatment on memory deficits and cognitive decline. Two behaviouraltests commonly used to assess cognitive deficits in rodents wereemployed to assay effects on short-term memory (Y-maze test) andlong-term memory (step-through passive avoidance test). The Y-maze istest of short-term memory, assessing spatial working memory andexploratory behaviour by measuring spontaneous alternations, which isthe frequency of entering a new arm of the maze rather than returning toone that was previously visited (described in methods). The step-throughpassive avoidance test measures associative long-term memory byassessing the learning of an association of an aversive stimulus to aparticular context (described in methods). SAMP8 mice have measurabledeficits in both tests as they age.

Methods

The experiment was carried out using SAMP8 mice with the followingtreatment groups: SAMP8 vehicle treated (n=24) and SAMP8 semaglutide (30nmol/kg) treated (n=11). Treatment was commenced at six weeks of age.Treatment was delivered subcutaneously once a day, with an initialtitration period of for semaglutide of 3 nmol/kg on the first day ofdosing, 10 nmol/kg on the second day of dosing and proceeding with 30nmol/kg thereafter.

Testing in the Y-maze was performed at 8 weeks of age and 16 weeks ofage, at approximately 15 and 71 days following treatment initiationrespectively. The Y-maze was comprised of grey polyvinylchloride withthree arms 40 cm long, 13 cm high, 3 cm wide at the bottom, 10 cm wideat the top converging at an equal angle. Each mouse was placed at theend of one arm and allowed to move freely through the maze during aneight minute session. The series of arm entries including possiblereturns into the same arm was monitored and alternation was defined asentries into all three arms on consecutive occasions. The number ofmaximum alternations was therefore the total number of arm entries minustwo and the percentage of alternation was be calculated as (actualalternations/maximum alternations)×100.

The step through passive avoidance performance was performed at 18 weeksof age. Testing was performed in an apparatus comprising of atwo-compartment box (15×20×15 cm high) where one compartment wasilluminated with white polyvinylchloride walls and the other wasdarkened with black polyvinylchloride walls and a grid floor. Aguillotine door separated the compartments. A 60 W lamp positioned 40 cmabove the apparatus illuminated the white compartment during theexperiment. Scrambled footshocks (0.3 mA for 3 s) could be delivered tothe grid floor using a shock generator scrambler (Lafayette Instruments,Lafayette, USA). A training session was first performed where theguillotine door was initially closed and each mouse was placed into thewhite compartment. After 5 s, the door was raised. When the mouseentered the darkened compartment and placed all four paws on the gridfloor, the door was closed and the footshock delivered for 3 s toassociate the darkened chamber with a footshock. A retention test wascarried out 24 h after training. Each mouse was again placed into thewhite compartment and after 5 s, the door was raised. The step-throughlatency was recorded up to 300 s, defined as the time it took the mouseto enter the darkened compartment during the retention test. Escapelatency was as recorded, defined as the time in the retention test toescape the darkened chamber following the application of a footshock.

Results

Data in FIG. 7 illustrates that vehicle-treated SAMP8 mice had, asexpected, significantly decreased percentage alternation behaviour inthe Y-maze at 16 weeks (mean±SEM: 42.8%±2.1%) versus 8 weeks (mean±SEM:69.1%±1.3%) of age (p<0.0001, 2-way ANOVA, Sidak's multiple comparisontest). Semaglutide-treated SAMP8 mice at 16 weeks of age hadsignificantly improved alternation behaviour (mean±SEM: 79.1%±1.6%)compared to vehicle-treated SAMP8 (mean±SEM: 42.8%±2.1%) controls(p<0.0001, 2-way ANOVA, Sidak's multiple comparison test). These datashow semaglutide has a positive effect on preserving short term memoryfunction in SAMP8 mice as measured in the Y maze test.

Semaglutide also improved long-term memory in SAMP8 mice as measured inthe step-through passive avoidance test (FIG. 8-9 ). Semaglutide-treatedSAMP8 mice had significantly increased step-through latency into thedarkened chamber during the retention phase, which was previouslyassociated with a footshock (FIG. 8 ; SAMP8 vehicle-treated mean±SEM:109.8 seconds±5.8 seconds; SAMP8 semaglutide-treated mean±SEM: 260.5seconds±14.5 seconds, p<0.0001, Mann-Whitney test). Semaglutide-treatedSAMP8 mice also had significantly lower escape latency from the darkenedchamber (FIG. 9 ; SAMP8 vehicle treated mean±SEM: 88.8 seconds±4.6seconds; SAMP8 semaglutide-treated mean±SEM: 19.0 seconds±3.0 seconds,p=0.01, unpaired t test).

Semaglutide treatment did not result in differences in body weight (16weeks of age; SAMP8 vehicle-treated mean±SEM: 31.0 grams ±0.43 grams or148.0%±4.6% change in body weight from baseline; SAMP8semaglutide-treated mean±SEM: 29.2 grams ±0.7 grams or 145.4%±4.2%change in body weight from baseline) or blood glucose (SAMP8vehicle-treated mean±SEM: 137.1 mg/dL ±5.6 mg/dL; SAMP8semaglutide-treated mean±SEM: 133.1 mg/dL ±2.2 mg/dL) compared tovehicle treated animals.

CONCLUSION

Chronic semaglutide treatment prevented cognitive decline in SAMP8 mice.Semaglutide prevented decline in alternation behaviour in the Y-maze,indicating improved short-term and spatial memory compared tovehicle-treated SAMP8 controls. Semaglutide also prolonged thestep-through latency and shortened the escape latency in thestep-through passive avoidance test, which are positive indicators oflonger-term memory performance and associative learning. These positiveeffects on cognitive parameters furthermore appear to be a novel effectof semaglutide that is not driven by changes in glycaemia or bodyweight. Example 2 surprisingly shows better effects of semaglutide thanthose published for liraglutide in the same animal model.

Example 3—Semaglutide Reduces Brain Inflammation (Neuroinflammation) ina Lipopolysaccharide (LPS) Inflammation Mouse Model

Neuroinflammation is part of the pathology comprising dementia andAlzheimer's disease, with human brain imaging studies highlightingincreased markers of inflammation in Alzheimer's disease (e.g.translocator protein 18 kDa levels) and genetic association studies inhumans highlighting that genes associated with Alzheimer's disease arepart of inflammatory pathways. Inflammation is also linked to metabolicdisease in humans (obesity, type 2 diabetes, cardiovascular diseases)and thus could affect progression of cognitive decline and dementia inpeople with metabolic diseases.

LPS-induced neuroinflammation is used as a non-genetic model ofAlzheimer's disease in rodents. LPS is an endotoxin from gram-negativebacteria that provides a persistent inflammatory stimulus activatingbrain immune cells (neuroimmune cells). Microglia are a brain immunecell type activated by LPS, and the degree of neuroinflammation can beassessed by the area of microglia in brain tissue as measured by themicroglia-specific marker ionized calcium binding adaptor molecule 1(lba1).

Here, LPS-induced neuroinflammation in mice was used to assess theimpact of semaglutide on attenuating brain inflammation in thehippocampus, a brain region involved in memory and learning which isdeteriorated in Alzheimer's Disease.

Methods

The experiment was carried out using C57BL/6 mice at 8-10 weeks of age.Mice were treated with semaglutide (30 nmol/kg, subcutaneously once perday) or vehicle from Day 1 to Day 28 of the study. To induceinflammation, LPS was administered (1.0 mg/kg, intraperitoneally onceper day) for three days at days 15-17 of the study, with control animalsreceiving vehicle. Induction of inflammatory cytokines was verified bymeasuring plasma tumor necrosis factor alpha levels on Day 15, one hourafter LPS dosing. Animals were terminated at either Day 19 (Day 2 afterLPS treatment) or Day 28 (Day 11 after LPS treatment) for to measuremarkers of neuroinflammation. All treatment groups had n=8-12.

Immediately after termination, whole brains were collected forimmunohistochemical (IHC) analyses of neuroinflammation markers. Brainswere immersion fixated in 10% neutral buffered formalin forapproximately 48 h and then transferred to 70% ethanol and stored at 4°C. until paraffin embedding in blocks. Serial sections representing therostro-caudal axis of the dorsal hippocampus were cut at 4 μm andcollected on Superfrost plus slides. Paraffin embedded sections werede-paraffinated in xylene and rehydrated in series of graded ethanol.IHC for lba1 was performed using lba1 primary antibody (Abcam, Cat.Ab178845). Following antigen retrieval and blocking of endogenousperoxidase activity, slides were incubated with primary antibody. Theprimary antibody was detected using a linker secondary antibody followedby amplification using a polymeric HRP-linker antibody conjugate. Next,the primary antibody was visualized with DAB as chromogen andcounterstained in hematoxylin.

Quantitative assessment of lba1 signal was performed to measure the areaof microglia in the hippocampus of the tissue section. Assessment wasperformed using a two-step protocol with VIS (Visiopharm, Denmark)software. First, crude detection of tissue at low magnification (1 ×objective) and delineation of the Region of Interest (ROI) was obtained.Second, detection of IHC-positive staining was performed at highermagnification (10 × objective) inside the ROI. The quantitativeestimates of IHC-positive staining were calculated as an area fraction(AF) of the total tissue area where:

${AF}_{{IHC} - {{positive}{signal}}} = \frac{{Area}_{{IHC} - {{positive}{signal}}}}{{Area}_{{IHC} - {{positive}{signal}}} + {Area}_{tissue}}$

Results

Semaglutide lowered the microglial inflammatory marker lba1 in thehippocampus following LPS administration. Results in FIG. 10 show thatLPS significantly increased hippocampal lba1 area on Day 19 in micedosed with LPS+ vehicle compared to vehicle/vehicle dosed controls(p<0.001, Dunnett's test one-factor linear model; Day 19 vehicle/vehiclemean±SEM: 8.98%±0.34%, Day 19 LPS+ vehicle mean±SEM: 14.25%±0.54%)illustrating that neuroinflammation was induced by LPS. On Day 28, whileLPS+ vehicle treated mice continued to have a significantly higher areaof hippocampal lba1 (p<0.05 vs vehicle/vehicle controls, Dunnett's testone-factor linear model; Day 28 vehicle/vehicle mean±SEM: 9.77%±0.54%,Day 28 LPS+ vehicle mean±SEM: 12.17%±0.88%), semaglutide treatmentsignificantly reduced lba1 area in LPS+ semaglutide-treated mice (p<0.01vs LPS+ vehicle treated mice, Dunnett's test one-factor linear model;Day 28 LPS+ vehicle mean±SEM: 12.17%±0.88%, Day 28 LPS+ semaglutidemean±SEM: 8.53%±0.49%).

There was no meaningful difference in body weight at Day 28 between micedosed with LPS+ vehicle (mean±SEM: 23.83 g ±0.33 g) versus those treatedwith LPS+ semaglutide (mean±SEM: 22.98 g ±0.70 g).

CONCLUSION

In an LPS-induced neuroinflammation model, semaglutide reducedneuroinflammation in both the hippocampus as measured by the area ofmicroglia (lba1). Semaglutide treatment reduced neuroinflammationimplicating that this may be a novel mechanism through with semaglutidemay have effects on cognition.

While certain features of the invention have been illustrated anddescribed herein, many modifications, substitutions, changes, andequivalents will now occur to those of ordinary skill in the art. It is,therefore, to be understood that the appended claims are intended tocover all such modifications and changes as fall within the true spiritof the invention.

1. A method for treating Alzheimer's disease, comprising administeringsemaglutide to a subject in need thereof.
 2. The method according toclaim 1, wherein the subject has mild cognitive impairment or milddementia.
 3. The method according to claim 1, wherein the semaglutide isthe sole pharmaceutically active ingredient administered to the subject.4. The method according to claim 1, wherein the semaglutide isadministered subcutaneously.
 5. The method according to claim 1, whereinthe semaglutide is administered orally.
 6. The method according to claim1, wherein the semaglutide is administered in a tablet comprising a saltof N-(8-(2-hydroxybenzoyl)amino)caprylic acid.
 7. The method accordingto claim 1, further comprising administering the semaglutide for atleast 12 months.
 8. The method according to claim 6, wherein the salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid is sodiumN-(8-(2-hydroxybenzoyl)amino)caprylate.
 9. The method according to claim2, wherein the subject has mild cognitive impairment.
 10. The methodaccording to claim 9, wherein the semaglutide is administeredsubcutaneously.
 11. The method according to claim 9, wherein thesemaglutide is administered orally.
 12. The method according to claim 9,wherein the semaglutide is administered in a tablet comprising a salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid.
 13. The method according toclaim 12, wherein the salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acidis sodium N-(8-(2-hydroxybenzoyl)amino)caprylate.
 14. The methodaccording to claim 2, wherein the subject has mild dementia.
 15. Themethod according to claim 14, wherein the semaglutide is administeredsubcutaneously.
 16. The method according to claim 14, wherein thesemaglutide is administered orally.
 17. The method according to claim14, wherein the semaglutide is administered in a tablet comprising asalt of N-(8-(2-hydroxybenzoyl)amino)caprylic acid.
 18. The methodaccording to claim 17, wherein the salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid is sodiumN-(8-(2-hydroxybenzoyl)amino)caprylate.
 19. The method according toclaim 3, wherein the semaglutide is administered subcutaneously.
 20. Themethod according to claim 3, wherein the semaglutide is administeredorally.
 21. The method according to claim 3, wherein the semaglutide isadministered in a tablet comprising a salt ofN-(8-(2-hydroxybenzoyl)amino)caprylic acid.
 22. The method according toclaim 21, wherein the salt of N-(8-(2-hydroxybenzoyl)amino)caprylic acidis sodium N-(8-(2-hydroxybenzoyl)amino)caprylate.